IMPORTANCE Medicare payment initiatives are spurring efforts to reduce potentially avoidable hospitalizations. OBJECTIVE To determine whether training and support for implementation of a nursing home (NH) quality improvement program (Interventions to Reduce Acute Care Transfers [INTERACT]) reduced hospital admissions and emergency department (ED) visits. DESIGN, SETTING, AND PARTICIPANTS This analysis compared changes in hospitalization and ED visit rates between the preintervention and postintervention periods for NHs randomly assigned to receive training and implementation support on INTERACT to changes in control NHs. The analysis focused on 85 NHs (36 717 NH residents) that reported no use of INTERACT during the preintervention period. INTERVENTIONS The study team provided training and support for implementing INTERACT, which included tools that help NH staff identify and evaluate acute changes in NH resident condition and document communication between physicians; care paths to avoid hospitalization when safe and feasible; and advance care planning and quality improvement tools. MAIN OUTCOMES AND MEASURES All-cause hospitalizations, hospitalizations considered potentially avoidable, 30-day hospital readmissions, and ED visits without admission. All-cause hospitalization rates were calculated for all resident-days, high-risk days (0-30 days after NH admission), and lower-risk days (31 days after NH admission). RESULTS We found that of 85 NHs, those that received implementation training and support exhibited statistically nonsignificant reductions in hospitalization rates compared with control NHs (net difference, -0.13 per 1000 resident-days; P = .25), hospitalizations during the first 30 days after NH admission (net difference, -0.37 per 1000 resident-days; P = .48), hospitalizations during periods more than 30 days after NH admission (net difference, -0.09 per 1000 resident-days; P = .39), 30-day readmission rates (net change in rate among hospital discharges, -0.01; P = .36), and ED visits without admission (net difference, 0.02 per 1000 resident-days; P = .83). Intervention NHs exhibited a reduction in potentially avoidable hospitalizations overall (net difference, -0.18 per 1000 resident-days, P = .01); however, this effect was not robust to a Bonferroni correction for multiple comparisons. CONCLUSIONS AND RELEVANCE Training and support for INTERACT implementation as carried out in this study had no effect on hospitalization or ED visit rates in the overall population of residents in participating NHs. The results have several important implications for implementing quality improvement initiatives in NHs.
Bibliographical noteFunding Information:
Accepted for Publication: May1,2017. Published Online: July 3, 2017. doi:10.1001/jamainternmed.2017.2657 Author Contributions: Dr Huckfeldt had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kane, Huckfeldt, Tappen, Newman, Ouslander. Acquisition,analysis,orinterpretationofdata:Allauthors. Drafting of the manuscript: Kane, Huckfeldt, Newman, Yang, Ouslander. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kane, Huckfeldt, Newman, Yang. Obtained funding: Kane, Tappen, Ouslander. Administrative, technical, or material support: Kane, Tappen, Engstrom, Rojido. Studysupervision:Kane,Huckfeldt,Tappen,Ouslander. Conflict of Interest Disclosures: Dr Ouslander is a full-time employee of Florida Atlantic University (FAU) and has received support through FAU for research on INTERACT from the National Institutes of Health, the Centers for Medicare & Medicaid Services, The Commonwealth Fund, the Retirement Research Foundation, the Florida Medical Malpractice Joint Underwriting Association, PointClickCare, Medline Industries, and Think Research; he and his wife had ownership interest in INTERACT Training, Education, and Management (I TEAM) Strategies, LLC, which had a license agreement with FAU for use of INTERACT materials and trademark for training during the time of the study, and they receive royalties from Pathway Health, which currently holds the license. Dr Ouslander also serves as a paid advisor to Pathway Health, Think Research, and Curavi. Work on funded INTERACT research is subject to the terms of conflict of interest management plans developed and approved by the FAU financial conflict of interest committee. Funding/Support: This study was supported by the National Institute for Nursing Research (grant No. 1R01NR012936), and Medline Industries provided support for components of an online training program used during the study. Role of the Funder/Sponsor: The funders/ sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: The authors thank the nursing homes and nursing home staff that participated in the study, as well as Jill Shutes, GNP; David Wolf, PhD; Laurie Herndon, GNP; and Alice Bonner, PhD, GNP, for assistance with training and implementation support. We thank Mark Woodhouse for programming support. Additional Information: Our colleague and coauthor, Robert L. Kane, MD, passed away after the initial submission of this manuscript. As in all of his work, his remarkable research insights were instrumental in the design of this study and the interpretation of the results. We mourn his loss.